We congratulate McNamara et al. (1) for these exciting new data on a cohort of 100 women diagnosed with peripartum cardiomyopathy (PPCM). This study adds important information with regard to ethnic differences and prognosis as the current management allows it.

However, we noted that several patients had a left ventricular ejection fraction (LVEF) above 45% at the point defined as “baseline” (Figures 2 and 3), although the authors state in the Methods section that they used the inclusion criteria of LVEF<45%. Thus, the cohort includes less sick patients with notoriously better outcomes than in other cohorts. The authors should explain this discrepancy.

A second point concerns the definition of full recovery. In the European and African PPCM studies, full recovery is defined as reaching an LVEF above 55% (2,3). Looking at the graphs in Figures 2 and 3, the recovery rate would be considerably lower if these criteria would have been used. For better comparison with the African and European collective, could the authors provide the rate of full recovery in their collective using LVEF >55% as the cutoff?

Finally, the authors state that 15% of PPCM patients in their collective were breastfeeding at the time of diagnosis. Looking at the epidemiological data published by the Centers for Disease Control and Prevention in 2014, 79% of all women in the United States are breastfeeding their newborns and 49% are still breastfeeding 6 months after delivery (4).

Why was the rate of breastfeeding mothers among PPCM patients so low? With regard to outcome, what was the baseline LVEF in breastfeeding PPCM patients and how long did they continue breastfeeding after inclusion?

Importantly, no controlled clinical studies have ever been performed analyzing the effects of heart failure medication transferred to the infant in the breast milk. By contrast, data from our team has demonstrated normal growth percentiles and no adverse outcome for the infants in a collective of PPCM patients in South Africa (PPCM patients mainly living in Soweto and rural South African regions) where breastfeeding has been terminated (5), suggesting no disadvantage for infants if their severely diseased mothers did not nurse them.

Taken together, we feel that the conclusion of the authors that breastfeeding is safe in PPCM patients appears premature and eventually even misleading.

Footnotes

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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